The ‘devolution revolution’ is more than just legislation | Matthew Macnair-Smith

Jigsaw puzzle piece

Ever since the Greater Manchester devolution deal was made public, devolution has been moving up the political agenda. The summer Budget saw the announcement of another such deal in Cornwall, and I’m sure many more will follow as local areas consider how best to realise their local ambitions.

Against this backdrop, the Cities and Local Government Devolution Bill (the Devolution Bill) has been steadily making its way through Parliament, having just completed its first stage of parliamentary scrutiny in the House of Lords. 

Clause six has potentially the greatest implication for NHS organisations, as it seeks to allow local authorities to take on or share the functions of other public authorities – including NHS bodies. 

So far, devolution in Manchester hasn’t concerned itself with one public authority seeking to dominate another. Rather, it has been based on developing strong relationships between NHS and local authority bodies, aligning around the needs of their population. 

As both the clinical commissioning group and local authority leaders told us in their address to the Confed conference in June, their plans are not a takeover of health functions by local authorities, or vice versa. Instead, they are a partnership of leaders trying to put people and place above organisational interest. 

The Manchester arrangement stemmed from substantial groundwork by local leaders who hammered out a deal agreed by no less than 37 different organisations, including local NHS providers. Significantly, they also had to negotiate the deal directly with the Treasury. 

While Manchester’s path can’t be used as the blueprint for all local plans, the government’s desire to see this sort of process repeated in other local areas gives some reassurance that it wants devolution plans to be borne out of local conversations and agreements. Any further devolution deals will require local, ministerial and parliamentary approval. 

Conditions, not legislation

Nevertheless, we need to be careful not to confuse legislation with the actual conditions that make local devolution work.

The partnership working and plans in Greater Manchester occurred without central government action. They are the culmination of work over many years to forge local relationships and agree shared priorities, based on a shared understanding of the population’s health needs. Creating the culture to enable this type of relationship takes time and effort. 

Politicians and policymakers in Westminster can draft bills that legally enable devolution, but creating the right environment is down to local leadership. 

What will be really important in getting this policy right is understanding some of the universal principles behind forging a conducive culture and environment. And trust will be a key element. In practice, this means involving all local health and care organisations in the development of proposals – local authorities, commissioners and providers all engaging with each other, and the local population, regarding their plans. 

Equally, local people need to be able to trust that devolution arrangements have been developed in partnership with patients and the public, reflecting people’s understanding of their own needs and aspirations. 

Inclusive leadership

But all of this requires the right leaders; leaders who put the needs of the population at the heart of what they’re doing, rather than that of their individual organisations and institutions. Leaders who recognise the strengths inherent in both clinically led commissioning and democratically elected decision-making; those able to see that proposals can be made stronger as a result of input and engagement from both NHS and local councillors. Central government and national bodies have a role in ensuring there is the right environment to allow this sort of leadership to flourish. 

Many Confed members are cautiously supportive of the government’s move towards enabling devolution. Over the coming weeks, we’ll be engaging further with members  to continue to shape our response to this agenda. It’s important that at national level, policy and legislation are enabling devolution to happen, with the right safeguards in place. And, where necessary, that we properly understand the potential implications for NHS bodies.

But this isn’t just about the bill – culture is key. We need to use the freedoms made available through the legislation to end the silo mentality of individual organisations working in isolation. Instead, local leaders must collaborate, pool resources and integrate planning and delivery to better meet local people’s needs.  

Matthew Macnair-Smith is a policy and research manager at the NHS Confederation. Follow the organisation on Twitter @nhsconfed

The Devolution Bill: What could it mean for the NHS?

Read our summary of the bill and what it could mean for NHS organisations.

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